Fo o d Po v e r t y a n d H e a l t h Food Poverty and Health Briefing Statement Introduction In the UK, the poorer people are, the worse their diet, and the more diet-related diseases they suffer from. This is food poverty.1 Poor diet is a risk factor for the UK’s major killers of cancer, coronary heart disease (CHD) and diabetes. Yet it is only in the past few years that the immense contribution it makes to poor health has been quantified: poor diet is related to 30% of life years lost in early death and disability.1 Inequalities in people’s diets can result in inequalities in people’s health. Those on low incomes suffer from poor diets, as evidenced by lower fruit and vegetable intakes, and a higher prevalence of dental caries among children. They are also disproportionately affected by the major killer diseases. It is estimated that as many as 10 million people in the UK live in poverty, including nearly three million children.2 Tackling food poverty is recognised as key to achieving government targets on reducing inequalities and priority health areas including cancer, CHD and older people and children. However, action needs to be more than health professionals giving advice to individuals. It must change the ‘food environment’ – that is, accessibility, affordability, culture – in which people live. Public health professionals are ideally placed to take the lead on this – through developing local strategies and programmes to remove the barriers to healthy eating and thus improve the nutrition of people living in food poverty. Evidence The Department of Health (England) recognises food poverty as “the inability to afford, or to have access to, food to make up a healthy diet.” 3 Faculty of Public Health Briefing Statement Food Poverty and Health 2 Food poverty and effects on health shift towards the recommended balanced diet. Key Poor diet is a major health risk. It contributes to: benefits include: ■ almost 50% of CHD deaths4 ■ lowering cholesterol levels by just 10% in the UK ■ 33% of all cancer deaths5 would prevent approximately 25,000 deaths every year.10 This could easily be achieved ■ increased falls and fractures in older people6 through a reduction in saturated fat intakes ■ low birthweight and increased childhood ■ consuming fruit and vegetables has a strong morbidity and mortality7 protective effect against stroke11 ■ increased dental caries in children.8 ■ reducing salt (sodium) intake decreases the risk of hypertension (persistent high blood pressure) There is also growing evidence to support the link and therefore risks in cardiovascular diseases between poor diets and anti-social behaviour. In a such as CHD/stroke12 placebo-controlled study in men’s prison, vitamin, ■ 0.8mg of folic acid per day reduces serum mineral and essential fatty acid supplements were homocysteine by 3mmol, leading to a 16% associated with a decrease of 37% in serious reduction in CHD and a 24% reduction in incidents.9 stroke13 A poor diet is characterised by excessive intakes of ■ about 40% of endometrial cancer, and 10% of saturated fat, salt or sugar, and an insufficient breast and colon cancers would be avoided by consumption of fruit and vegetable, and dietary maintaining a healthy weight of a BMI of under fibre.1 25kg/m2 14 ■ increased dietary fibre is associated with a Those who are most likely to experience food decreased risk of colorectal and pancreatic poverty are:1 cancer15 ■ people living on low incomes or who are ■ childhood fruit consumption may have a long unemployed term protective effect on cancer risk in adults.16 ■ households with dependent children The Nutrition and Food Poverty toolkit provides ■ older people comprehensive advice on what constitutes a healthy ■ people with disabilities diet.1 ■ members of black and minority ethnic communities Food poverty and inequalities Food poverty results primarily from inequalities, of Modern Malnutrition diet, diseases related to poor diet, socioeconomic Diets high in fat, sugar and salt can result in status, geographical region and ethnicity. overweight and obesity – particularly when a person’s intake from food and drink exceeds the Inequalities in diet energy they use. A poor diet which results in ■ People on low incomes eat more processed foods overweight/obesity is known as ‘modern which are much higher in saturated fats and malnutrition’. A significant proportion of the salt.7 They also eat less variety of foods.17 This is population is failing to meet current recommended related to economies of scale and fear of dietary requirements. For example, in England:1 potential waste. ■ People living on state benefits eat less fruit and ■ children and adults eat 50% more saturated fat vegetables, less fish and less high-fibre than the recommended level breakfast cereals.18 ■ children eat only one quarter, and adults only ■ People in the UK living in households without an half the recommended levels of fruit and earner consume more total calories, and vegetables considerably more fat, salt and non-milk ■ children eat 50% more sugar than the extrinsic sugars than those living in households recommended level. with one or more earners.19 Modern malnutrition is more common in people from Inequalities in diet-related diseases lower socioeconomic groups.1 Socioeconomic differences account for 5,000 deaths a year in men aged under 65 years of age.7 In all age The benefits of healthy eating groups, people living on a low income have higher Significant health benefits can be achieved at both rates of diet-related diseases than other people. the population and individual level by enabling a Faculty of Public Health Briefing Statement Food Poverty and Health 3 ■ In men, 58% more manual workers die ■ Food labelling can be difficult to interpret and prematurely from CHD than non-manual even misleading, for example a fatty food which workers.20 claims to have no cholesterol is still a fatty food. ■ The prevalence of obesity among women in ■ Food marketing – 99% of food and drink social class V is twice that of women in social advertised to children during Saturday morning class I.21 children’s television programming were high in ■ Diabetes is one and a half times more likely to fat or sugar or salt. develop in people in the most deprived 20% of the population compared with the general Policy Context population.22 There are a number of government health policies ■ Babies with fathers in social classes IV and V have a birthweight on average 130g lower than designed to address the issue of food poverty, both babies with fathers in social classes I and II.7 directly and indirectly. The Nutrition and Food ■ In women, the premature death rate from CHD Poverty Toolkit1 gives details of relevant policies and is more than double in manual workers, strategies. However, key drivers include: compared with non-manual workers.23 UK: The Healthy Start scheme aims to improve ■ People from lower socioeconomic backgrounds are less likely to survive some cancers. For nutrition, particularly for pregnant women, mothers example, the difference in breast cancer and and young children, through making a wider choice colon cancer five-year survival rates between of foods available, including fruit and vegetables. the most deprived and the most affluent are 7% Healthy Living Centre Programmes target the most and 4% less, respectively.24 deprived areas and groups. They seek to address the wider determinants of health including the social Geographical inequalities and economic aspects of deprivation such as social There are significant regional variations in diet- exclusion, and poor service access. related disease in the UK. For example, there is a steady rise in obesity rates in men, the further north Sure Start is a UK-wide programme which aims to they live.1 deliver the best possible start in life to children in deprived communities. It offers opportunities for Ethnicity early interventions to prevent poor health in later There are differences in diet-related disease in life. Responsibility for delivering Sure Start in different ethnic groups. For example, stroke Scotland, Wales and Northern Ireland rests with the mortality rates are around 50% higher in South devolved administrations. Asian and black Caribbean men and women than in the general population.1 England and Wales: The 5 A DAY programme is part of prevention strategies to reduce deaths from Barriers to healthy eating cancer and CHD. It includes the School Fruit and In order to eradicate inequalities in nutrition, the Vegetable Scheme, and working with industry to main barriers to eating healthily must be removed. improve access to fruit and vegetables. Some These include:1 aspects of the programme do not apply in Wales. ■ Low income and debt making healthier foods England: Choosing a Better Diet: a Food and Health (which are generally more expensive) such as Action Plan outlines government action to improve fresh fruit and vegetables, less affordable. diet. It focuses on providing better information, and ■ Poor accessibility to affordable healthy foods increased choice and access to healthier food. It also – linked to the closure of shops in deprived areas aims to reduce the prevalence of diet-related (leading to increased cost, poor quality and disease, obesity and improve the nutritional balance choice in remaining local shops), and to the of the average diet. Choosing Health: Making development of out-of-town supermarkets which Healthy Choices Easier is the overarching public may have poor public transport links. health white paper which looks at the wider ■ Factors in food production and the food chain, determinants and barriers to choosing a healthy such as the nutrient content of easily available, lifestyle, including inequalities, physical activity etc. cheap, processed foods which can be high in fat, sugar or salt. The Department of Health Public Service Agreement ■ Poor literacy and numeracy skills are barriers (PSA) sets objectives to substantially reduce the to information on maintaining a healthy diet, mortality rates from the major killer diseases as well as household budget management and halt the year-on-year rise in obesity among children. employment. Faculty of Public Health Briefing Statement Food Poverty and Health 4 Tackling Health Inequalities: A Programme for Action sets out the government’s strategy to deliver The Faculty of Public Health has produced, in the PSA health inequalities targets, focusing on low- association with the National Heart Forum, the income and minority ethnic groups who are Government Office for the North West, the disproportionately affected by the major diseases. Government of the West Midlands and the West Midlands Public Health Observatory, Nutrition and Scotland: Eating for Health – Meeting the Challenge Food Poverty. A toolkit for those involved in integrates the Scottish Executive’s food policy and developing or implementing a local nutrition key partner strategies to promote healthy eating and food poverty strategy.1 The toolkit is and achieve Scottish Dietary Targets. designed to help professionals tackle food poverty at local level. It outlines the barriers to healthy The Scottish Community Diet Project seeks to eating and the role poor diet plays in the major improve Scotland’s diet and health through killer diseases. Nutrition and Food Poverty forms supporting low-income communities. It offers a part of a wider campaign of work, in partnership grant scheme for community initiatives to improve with key health organisations, aimed at promoting diet and health. healthier lifestyles to reduce disease burden through the production of toolkits on the wider Wales: Food and Well Being – Reducing Inequalities determinants of health including hypertension, through a Nutrition Strategy for Wales outlines key physical activity, obesity and fuel poverty. actions to improve diet in Wales. Recommendations include increasing fruit and vegetable intake, as well as ensuring national and local policies are in place to Recommendations remove barriers to healthy eating. The Community Food Initiative provides a limited Improving nutrition and eradicating food poverty are number of grants from the Welsh Assembly essential to national strategies concerned with Government to increase healthy eating, particularly tackling inequalities and healthy priorities, including amongst the most disadvantaged groups. the major diseases of cancer, CHD and stroke. Primary care organisations and local authorities, in Northern Ireland: The Health Promoting Schools association with other local organisations, should Initiative envisages the school as a setting which develop nutrition and food poverty strategies and can offer considerable opportunities for tackling programmes to reduce the barriers to healthy inequalities in health and contribute to a child’s eating. whole development. The Fresh Fruit in Schools pilot ■ Establish a local ‘food poverty partnership’ with aims to provide access to fruit for P1 and P2 children key organisations including health services, local within pilot areas. It also aims to promote authorities and voluntary organisations, for awareness and uptake of healthy eating. example, to develop a local food poverty Fit Futures: Focus on Food, Activity and Young strategy. The Nutrition and Food Poverty Toolkit1 People is an initiative to develop ideas for improving gives comprehensive advice on how to do this. the health and well-being of children and young ■ Work with local public sector service providers, people through encouraging and supporting healthy such as schools, hospitals, prisons etc, to and active lifestyles. develop procurement policies which ensure that good quality, healthy food is sourced locally Investing for Health is a framework for improving wherever possible. the health and well-being of people in Northern ■ Work with the local community to understand Ireland. It includes targets to reduce the gap in life their views on priorities, barriers and expectancy between the most affluent and the most opportunities – through community meetings, deprived communities. surveys and promote healthy eating. ■ Undertake a food mapping survey to identify International: The First Action Plan for Food and those shops where healthy food is affordable Nutrition Policy. WHO European Region 2000-2005 and accessible. focuses on the need to develop policies on nutrition ■ Develop local programmes to promote healthy that promote good health, and which contribute to eating and physical activity. Initiatives such as socioeconomic development as well as sustainable cooking clubs, for example, should be created to environments. encourage and develop cooking skills, and increase nutritional knowledge. Integrate food Details of policies and initiatives can be found in poverty with existing local programmes and Publications and Useful Organisations p.6. strategies, such as local obesity strategies. Faculty of Public Health Briefing Statement Food Poverty and Health 5 ■ Produce local information to explain the ● improving access to affordable, good quality importance of healthy diet and what constitutes foods for those without cars, for example a healthy diet, as well as listing local suppliers through improving public transport links and where good quality affordable food is available. supporting shopping-carrying schemes, or ■ Work to eliminate the barriers to healthy eating community delivery schemes from retailers. through: This can be considered in the planning and regeneration of town centres and residential ● providing help with money matters eg. areas through a local authority anti-poverty unit, ● improving nutrition through schools, for and ensuring benefit entitlements are example by providing breakfast before claimed school, to help children who are not given ● providing better housing conditions to tackle breakfast at home, and offering healthier lack of cooking equipment or storage to school meals. enable bulk buying References 7 Acheson D. 1998. evidence of causality from a Independent inquiry into meta-analysis. BMJ; 325: 1 Press V on behalf of the inequalities in health. London: 1202-06 National Heart Forum, Faculty The Stationery Office 14 Bianchi F, Kaaks R, Vainio H. of Public Health, Government 8 James WPT et al. 1997. Socio- 2002. Overweight, obesity Office for the North West, economic determinants of and cancer risk. The Lancet Government Office for the health: the contribution of Oncology; 3(9): 565 North East, and West Midlands nutrition to inequalities in Public Health Observatory. 15 Department of Health. 1998. health. BMJ; 314: 1545-55 2004. Nutrition and food Nutritional aspects of the poverty: a toolkit for those 9 Gesch CB et al. 2002. development of cancer: report involved in developing or Influence of supplementary of the working group on diet implementing a local nutrition vitamins, minerals and and cancer of the Committee and food poverty strategy. essential fatty acids on the on the Medical Aspects of London: National Heart Forum antisocial behaviour of young Food and Nutrition Policy. adults. British Journal of London: HMSO 2 National Statistics. 2005. First Psychiatry; 181:22-28 release. Households below 16 Maynard M et al. 2003. Fruit, average income statistics. 10 Unal B, Critchley JA, Capewell vegetables and antioxidants London: Department for Work S. 2004. Explaining the in childhood and risk of adult and Pensions decline in coronary heart cancer: the Boyd Orr cohort disease mortality in England study. BMJ; 316: 499-50417 3 Department of Health. 2005. and Wales between 1981 and Choosing a better diet: a food 17 Dowler E, Calvert C. 1995. 2000. Circulation 109: 1101- and health action plan. Nutrition and diet in lone 1107 London: Department of Health parent families in London. 11 Ness AR, Powles JW. 1997. London: Family Policy Studies 4 Yusuf S, Hawken S, Ounpuu S Fruit and vegetables, and Centre et al. 2004. Effect of cardiovascular disease: a potentially modifiable risk 18 Food Standards Agency. 2002. review. International Journal of factors associated with National Diet and Nutrition Epidemiology; 26(1): 1-13 myocardial infarction in 52 Survey: Adults Aged 16-64. countries (the INTERHEART 12 Maryon-Davis A, Press V on Volume 1. London: Food study): case-control study. behalf of the Faculty of Public Standards Agency Lancet; 364: 937-52 Health and National Heart 19 Department for Environment, Forum. 2005. Easing the 5 Doll R, Peto R. 1981. The Food and Rural Affairs. 2001. pressure: tackling causes of cancer: quantitative National Food Survey 2000. hypertension. A toolkit for estimates of avoidable risks London: The Stationery Office developing a local strategy to in cancer in the United States tackle high blood pressure. 20 Peterson S, Rayner R. 2003. today. Journal of the National London: Faculty of Public Coronary heart disease Cancer Institute; 66:1191-208 Health statistics. British Heart 6 Vellas B et al. 1986. Foundation Statistics 13 Wald DS, Law M, Mavis JK. Malnutrition and falls. The Database 2003. London: 2002. Homocysteine and Lancet; 336: 1447 British Heart Foundation cardiovascular disease: Faculty of Public Health Briefing Statement Food Poverty and Health 6 21 Joint Health Surveys Unit. Useful Organisations Acknowledgments 1999. Health Survey for England 1998. London: The 5 A DAY Programme Authors Stationery Office w: www.5aday.nhs.uk Modi Mwatsama 22 Department of Health. 2002. British Dietetic Association Food and Health Programme National Service Framework w: www.bda.uk.com Manager for Diabetes. London: Heart of Mersey Department of Health British Heart Foundation Heart information line: Lindsey Stewart 23 Joint Health Surveys Unit. 08450 70 80 70 Faculty of Public Health 2003. Health Survey for w: www.bhf.org.uk England 2001. London: The Series Editor Stationery Office British Nutrition Foundation Lindsey Stewart w: www.nutrition.org.uk 24 Department of Health. 2000. Produced by The NHS Cancer Plan. London: Child Poverty Action Group Faculty of Public Health Department of Health w: www.cpag.org.uk 4 St Andrew’s Place London NW1 4LB Community Food Initiative Publications t: 020 7935 3115 w: www.cmo.wales.gov.uk e: email@example.com Choosing a Better Diet: a Food Food Vision – Improving w: www.fph.org.uk and Health Action Plan (2005) Community Health and Choosing Health: Making Healthy Registered charity no: 263894 Well-being Choices Easier (2004) ISBN: 1-900273-20-9 Joint resource from the Food Public Service Agreement (2002) Standards Agency, Local Publication date: May 2005 Tackling Health Inequalities. A Government Association, Local Programme for Action (2003) Authorities Coordinators of The information provided in this statement is correct Department of Health Regulatory Services at the time of going to press. w: www.dh.gov.uk w: www.foodvision.gov.uk Design and print: www.fosterandlisle.co.uk Eating for Health – Meeting the Food Standards Agency Challenge (2004) w: www.food.gov.uk Scottish Executive w: www.scotland.gov.uk Fresh Fruit in Schools Healthy Promoting Schools First Action Plan for Food and Initiative Nutrition Policy. WHO European w: www.investingforhealthni Region 2000-2005 .gov.uk World Health Organisation Summary w: www.euro.who.int Healthy Living Centre Programmes This briefing gives an overview Fit Futures: Focus on Food, w: www.nof.org.uk of the inequalities related to Activity and Young People (2004) Investing for Health Healthy Start food poverty, and its w: www.investingforhealthni.gov.uk w: www.dh.gov.uk consequences including diet-related disease, as well as Food and Well Being – Reducing Local Government Association w: www.lga.gov.uk outlines the benefits and Inequalities through a Nutrition Strategy for Wales (2003) barriers to eating healthily. National Consumer Council Welsh Assembly Government The statement also makes www.ncc.org.uk Available from the Food Standards important recommendations Agency National Heart Forum for action that can be w: www.food.gov.uk w: www.heartforum.org.uk implemented at local level. Investing for Health (2003) Scottish Community Diet Project It is not intended as an Department of Health, Social w: www.dietproject.org.uk exhaustive resource but as a Services and Public Safety signpost to the key evidence, Sure Start w: www.dhsspsni.gov.uk w: www.surestart.gov.uk publications and organisations as a next step to Sustain w: www.sustainweb.org understanding and tackling this important public health issue.